ROENTGEN APPEARANCE AND SIGNIFICANCE

Transcription

1 APRIL, 1975 CASCADE STOMACH* ROENTGEN APPEARANCE AND SIGNIFICANCE By RHONA J. KELLER, M.D., MANSHO T. KHILNANI, M.D., and BERNARD S. WOLF, M.D. ANATOMICALLY, the fundus of the stomach is that portion of the vertical pant of the stomach above the level of the cardiac orifice.6 It has, however, been pointed out that this anatomic usage3 is not generally adopted by radiologists, who ordinarily speak of the fundus as the expanded upper portion of the stomach NEW YORK, NEW YORK A C E 1 I LI I I I without precise definition. Radiologic usage is somewhat clearer in the recumbent position either supine on prone, when the more horizontal expanded uppermost portion of the stomach is angulated on the vertically oriented body of the stomach. In the usual J-shaped stomach, the fundus lies in the same longitudinal axis as the L1 F 1 B I D F FIG. I. The stomach-normal and cascade. (A and B) Normal stomach, lateral and anteroposterior projections, erect. (C and D) Borderline, lateral and anteroposterior projections, erect. Despite the presence of a ridge, there is a single fluid level. (E and F) Cascade stomach, lateral and anteroposterior projections, erect. There is a well defined ridge and 2 separate fluid levels. * From the Department of Radiology, The Mount Sinai Hospital and the Mount Sinai School of Medicine, the City University of New York, New York, New York. 746

2 FIG. 2. The filled stomach-erect: borderline cascade. (A) In the left anterior oblique projection, the inferior wall of the fundus is defined by a horizontal ridge (arrows) created by the gas distended splenic flexure. (B) In the posteroanterior projection, the displacement of the posterior wall by the splenic flexure creates a pseudoloculus. Fia. 3. Cascade stomach: no lesion. (A) The erect posteroanterior projection shows an independent fluid level in the fundus (lower arrow) with overlapping of the fundus and upper part of the body of the stomach. The upper margin of the gas filled splenic flexure (upper arrow) is seen through the fundus. (B) The erect lateral view demonstrates posterior loculation of the fundus with an air-barium level (arrow). The gas filled splenic flexure indents the stomach in the region of the ridge. The body of the stomach is pushed forward and upward. The fundus remains in normal position.

3 748 R. J. Keller, M. T. Khilnani and B. S. Wolf APRIL, 1975 I FIG. 4. Nonpersistent cascade. (A and B) Spot roentgenograms from the initial stages of an upper gastrointestinal series demonstrate a cascade configuration with obvious posterior loculation of the fundus. (C) A large amount of barium opens the stomach. The cascade configuration disappears. Indentation by the splenic flexure of the colon on the stomach is seen (arrow). body of the stomach with the anterior and posterior walls in the same coronal plane as the anterior and posterior walls of the body of the stomach. Ordinarily, there is no clean demarcation between the upper part of the body and the fundus. All walls demonstrate a smooth, essentially straight, continuum. In some cases, however, the fundus is a posterior loculus either directly behind on slightly to the night on left. A ridge is then apparent posteriorly which produces a radiologically evident demarcation between the fundus and body of the stomach (Fig. I, A-F). If this ridge is not horizontal, but turns upward at its anterior end, the fundal loculus then lies inferiorly relative to the proximal portion of the body of the stomach. The fundus, in this situation, still lies in its usual position relative to the structures of the left upper quadrant but the proximal portion of the body of the stomach is in an abnormally anterior and superior position. When this type of stomach is filled with barium (in the erect position), static roentgenograms may demonstrate a separate fluid level

4 VOL. 123, No. 4 Cascade Stomach 749 Fo.. Pancreatic cyst secondary to carcinoma of the pancreas. (A) There is a persistent cascade in the erect position with no obvious explanation. (B) The right anterior oblique roentgenogram demonstrates a mass behind the stomach producing a ridge (arrows). The uninvolved left lateral margin of the body of the stomach (arrowhead) produces a double contour. The gas distended splenic flexure is seen through the barium laterally and is unrelated to the cascade. confined to the fundus. At fluonoscopy, barium first fills the dependent, posterior fundus to the highest level of the ridge and then spills or cascades into the body and antrum. It is the latter phenomenon which has been classically used in the roentgen literature to define the cascade stomach.6 7 Partial organoaxial volvulus of the stomach may, at times, simulate the appearance of a marked cascade configuration when the stomach lies in a transverse plane. The upward rotation of the greater curvature characteristic of volvulus and the low position of the candia cleanly differentiate this condition from the true cascade stomach. In this paper, we would like to use the term cascade stomach in a somewhat more precise fashion. In the erect position, the presence of a posterior ridge which delineates a boundary between the fundus and body of the stomach is used to define the presence of a cascade configuration. This definition would also include the classic description of the cascade deformity. We should, also, like to point out that the nonpathologic cascade configuration of the stomach is not as common as is generally believed. Many cascade stomachs are the result of intrinsic on extrinsic gastric lesions. Therefore, the recognition of this deformity in the erect position at the onset of a barium series should alert the radiologist to the possibility that an organic lesion may be present. NORMAL ROENTGENOGRAPHIC FINDINGS TTLe cascade configuration of the stomach which is seen in the absence of significant pathologic abnormality is most often associated with a gas distended distal trans-

5 750 R. J. Keller, M. T. Khilnani and B. S. Wolf APRIL, 1975 wall. (C) In the erect posteroanterior position the fixed cascade is obvious and the only abnormality. verse colon on proximal limb of the splenic flexure (Fig. 2, A and B; and 3, A and B). In these cases, the gas distended colon is located behind and somewhat to the left of the body of the stomach and displaces the body anteriorly thus creating the cascade configuration. The ridge formed at the junction of the fundal loculus and the body is sharp, well defined and either straight or convex toward the fundus. In the erect frontal projection, a double loculus created by overlapping of the fundus and body is evident. In the recumbent position, the junctional area between the body of the stomach and the more proximal fundal region is not clearly defined by barium and there are no sudden or sharp changes in the caliber, contour or direction of the stomach at any level. Radiologists are well acquainted with the difficulties involved in the adequate examination of the fundus in all patients. This difficulty is enhanced by the presence of the cascade configuration. Various maneuvers have been designed to perform a more adequate examination of the area.

6 VOL. 123, No. 4 Cascade Stomach 75 These include: oblique projections in the erect position, both night and left, and lateral views; filling the fundus of the stomach with barium, the patient supine, and then tilting the patient toward the erect position, spotting the fundus as the barium spills out of it; turning the patient, in the supine position, towards the left and the right while conducting a similar maneuver; and cross table lateral views. The left anterior oblique erect noentgenogram of the stomach is perhaps better suited to delineate the posterior wall of the upper portion of the body of the stomach because, in this position, the fundus is less likely to obscure the region. At times, although a cascade configuration is noted with the first few swallows of barium in the erect position, it disappears with further filling of the stomach (Fig. 4, A-C). Apparently, the weight of the intraluminal fluid in the antrum is such that the stomach is opened up and presents as a single chamber. A single barium air level is then seen. ROENTGEN-PATHOLOGIC FINDINGS We have been impressed by the fact that true physiological or normal cascade, using the above definition, is by no means as common as is ordinarily thought. Pa- FIG.. Cascade deformity secondary to postoperative adhesions: cholecystectomy. Persistent cascade (arrows) in the erect position post-cholecystectomy is most likely secondary to rotation of the body of the stomach anteriorly, superiorly and to the right due to adhesions forming in the region of the lesser omentum. FIG. 8. Cascade deformity secondary to postoperative changes: splenectomy. Persistent cascade (arrows) in the erect position secondary to lateral and superior displacement and rotation of the body of the stomach following splenectomy. tients with a cascade stomach have demonstrated a variety of lesions both intrinsic and extrinsic primarily related to the posterior wall of the stomach. Cascading secondary to anterior growth of a retrogastnic mass is a simple manifestation and easy to understand (Fig., A and B). In most instances, this is the result of a mass in the body and/or tail of the pancreas either FIG. 9. Cascade deformity secondary to eventration of the left hemidiaphragm. Eventration of the left hemidiaphragm documented for at least 8 years with no change in that period of time. A persistent cascade deformity is noted (arrows).

7 FIG. JO. Cascade secondary to gastric ulcer. (A) A persistent cascade deformity is noted in the erect position (arrow). In addition, a nondescript narrowing of the upper portion of the body of the stomach and the fundus is evident. (B) The prone right anterior oblique roentgenogram demonstrates an ulcerated area in the region of the ridge (arrows). This was proved to be a benign ulcer. malignant neoplasm or the result of pancreatitis and pseudo-cyst formation. A tumor of the adrenal may produce a similar configuration. If the mass infiltrates the posterior wall of the stomach as well, additional findings include shortening, irregularity and nodulanity of the ridge seen in the erect position and abrupt changes in the caliber, contour or direction of the upper portion of the stomach seen in the recumbent position (Fig. 6, A-C). Occasionally, even soft tissue intrusion into the lumen of the stomach may be observed. Cascading may also occur secondary to other extrinsic factors, e.g., adhesions with shortening of the ligamentous attachments of the stomach after abdominal surgery such as cholecystectomy (Fig. 7). After splenectomy, a somewhat similar FIG. I I. Cascade secondary to carcinoma of the stomach. (A) Persistent cascade in the erect position is manifested by a laterally directed pouch (arrows). There is no obvious mass. (B) The right posterior oblique roentgenogram in the supine position delineates a large ulcerated tumor (arrowheads) which is circumferential in the region of the ridge (arrows). Extrinsic extension of tumor is likely.

8 VOL. 123, No. Cascade Stomach 753 FIG. 12. Cascade secondary to carcinoma of the stomach. (A) A persistent cascade is seen in the erect position (arrows). At the cardia, a lobulated soft tissue mass is evident through the gas in the fundus. (B) The tumor in the fundus is delineated by irregular, curvilinear collections of barium with distorted mucosa between. (C and D) A nodular defect of the distal esophagus (upper arrows) and an irregular ulcerated area (lower arrows) in the fundus are seen. At operation, the tumor extended through the gastric wall posteriorly and was fixed to the posterior peritoneal wall. cascade deformity in the opposite direction may occur as a result of the body of the stomach occupying the additional space posteriorly and laterally (Fig. 8). Eventration of the left hemidiaphragm produces a cascade configuration by elevation of the body of the stomach with maintenance of the normal position of the candia (Fig. 9). Intrinsic disease of the stomach may also result in the cascade configuration. Chronic benign peptic ulcer may occur near the junction of the fundus and the body of the stomach on the posterior wall either medially on laterally (Fig. 10, A and B). These ulcers frequently are associated with considerable shortening of the wall about the ulcer either as a result of spasm on fibrosis.5 In addition, adhesions to adjacent organs as a result of posterior penetration of the ulcer through the gastric wall with persistent distensibility of the anterior gastric wall contribute to the cascade configuration. Intrinsic gastric carcinoma may also be associated with the presence of a cascade

9 754 R. J. Keller, M. T. Khilnani and B. S. Wolf APRIL, 1975 deformity (Fig. u, A and B; and 12, A-D). A prime factor in the development of a cascade of this type is most likely fixation of the posterior gastric wall to the posterior panietes by tumor extension. Elkeles2 describes several cases of carcinoma of the fundus, intrinsic and extrinsic, in which a pouch-like protrusion at the lower postenomedial border of the fundus was produced, in effect, a cascade configuration. CONCLUSION The examination of the gastric fundus is usually the most difficult pant of a complete examination of the stomach. It is important to realize that examination of this region in the presence of a cascade configuration requires even greater attention, despite the greater difficulty encountered. In the erect position, a persistent cascade configuration, as defined by the presence of a posterior ridge delimiting fundus from body, suggests the possibility of a high posterior gastric on netrogastnic lesion. A cascade stomach should not be considered physiologic on within normal limits until a detailed examination of the area is satisfactorily performed. R. J. Keller, M.D. Department of Radiology The Mount Sinai Hospital 100th Street and Fifth Avenue New York, New York I0029 REFERENCES. BERANBAUM, S. L., GOTTLIEB, C., and LEFFERT, D. Secondary gastric volvulus. Part III. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1954, 72, ELKELES, A. Pouch formation of gastric fundus as radiological sign of carcinoma of cardia. Brit. 7. Radiol., 1959,32, SCHOPS, T. La Grosse Tuberosit#{233} de L Estomac. G. Dorn et Cie, Editeurs, Paris, I SHANKS, S., and KERLEY, P. A Textbook of X-ray Diagnosis. Volume II. W. B. Saunders Company, Philadelphia, SINGLETON, A. C. Chronic gastric volvulus. Radiology, 1940, 34, 53-6!. 6. SOBOTTA, J., and MCMURRICK, J. P. Atlas and Textbook of Human Anatomy. Volume II. The Viscera Including the Heart. W. B. Saunders Company, Philadelphia, TEMPLETON, F. E. X-ray Examination of the Stomach. Revised edition. The University of Chicago Press, Chicago, 1964.

10 This article has been cited by: 1. Murat Taner Gulsen, Irfan Koruk, Metin Dogan, Yavuz Beyazit Diagnostic accuracy of cascade stomach by upper gastrointestinal endoscopy in patients with obscure symptoms: A multi-center prospective trial. Clinics and Research in Hepatology and Gastroenterology 35:6-7, [CrossRef] 2. Stephen E. RubesinCase [CrossRef] 3. J.-R. Mabiala Babela, E. Makosso, A. Mouko, C. Samba-Louaka, P. Senga La plicature gastrique chez l enfant : à propos de trois cas. Journal de Pédiatrie et de Puériculture 22:3, [CrossRef] 4. H. Østensen, P. G. Burhol, J. Heger Gastric Cascade: A Diagnosis without Clinical Importance?. Scandinavian Journal of Gastroenterology 18:4, [CrossRef]